Advanced Serology Workshop Hepatitis Coordinator’s Conference San Antonio, Texas January 26-30 2003 Linda Moyer Brigette Finkelstein

Agenda Introduction Game Show Serologic Overview Case Study Exercises Q & A

Hepatitis Jeopardy

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

What sign of hepatitis does this next picture portray? Hepatitis for $200 What sign of hepatitis does this next picture portray? What is…..?

What is…..? Jaundice HAV for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Take a look at this picture? Hepatitis for $300 Take a look at this picture? Hepatitis for $300

Which hepatitis virus is this …..? Hepatitis B Virus Hepatitis for $300

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Hepatitis for $400 In the dialysis setting, patients with which bloodborne pathogen(s) are isolated? What is…..?

What is…..? Hepatitis B Virus Hepatitis for $400

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Hepatitis for $500 Infection with hepatitis D virus (HDV) requires infection with what other virus ? What is…..?

What is…..? Hepatitis B Virus Hepatitis for $500

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HAV for $200 What is the most frequently reported source of HAV infection in the US? What is…..?

Household or sex contact with a person infected with HAV What is…..? Household or sex contact with a person infected with HAV HAV for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HAV for $300 After exposure, what is the maximum time frame allowed for the administration of IG? What is…..?

What is…..? 2 weeks HAV for $300

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

What is the IG dosage used in an HAV post exposure situation? Daily Double What is the IG dosage used in an HAV post exposure situation? Daily Double

What is…..? 0.02 mL/kg IM Daily Double

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

What is the H-BIG dosage used in an HBV post exposure situation? HBV for $100 What is the H-BIG dosage used in an HBV post exposure situation? What is…..?

What is…..? 0.06 mL/kg IM HBV for $100

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HBV for $200 What hepatitis B blood test should be done routinely on pregnant women during the 1st trimester? What is…..?

Hepatitis B Surface Antigen (HBsAg) What is…..? Hepatitis B Surface Antigen (HBsAg) HBV for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HBV for $400 What hepatitis B blood test can be used to distinguish immunity due to prior infection from immunity due to vaccination? What is…..?

Hepatitis B Core Antibody (Anti-HBc) What is…..? Hepatitis B Core Antibody (Anti-HBc) HBV for $400

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HBV for $500 In the U.S., what percentage of asymptomatic persons have a positive anti-HBc as their only HBV-marker? (isolated anti-HBc) What is…..?

What is…..? An average of 2% HBV for $500

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HCV for $200 What is the risk of getting infected from an HCV+ contaminated needlestick? What is…..?

What is…..? 1.8% HCV for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Daily Double Daily Double What is the percentage of persons with HCV infection that develop chronic liver disease? Daily Double

What is …..? 70% Daily Double

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

HCV for $500 How soon can HCV RNA be detected in serum or plasma after exposure to HCV? What is…..?

What is…..? 1-2 weeks HCV for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

What year did hepatitis B vaccine become commercially available? Vaccines for $200 What year did hepatitis B vaccine become commercially available? What is…..?

What is…..? 1982 Vaccines for $200

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

What year was hepatitis A vaccine first licensed? Vaccines for $300 What year was hepatitis A vaccine first licensed? What is…..?

What is…..? 1995 Vaccines for $300

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Vaccines for $400 What injections should be given to prevent perinatal transmission of HBV? What is…..?

Hepatitis B Vaccine + Hepatitis B Immune Globulin (H-BIG) What is…..? Hepatitis B Vaccine + Hepatitis B Immune Globulin (H-BIG) Vaccines for $400

HEPATITIS JEOPARDY Hepatitis HAV HBV HCV Vaccines 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

Final Jeopardy Final Jeopardy What two pharmaceutical companies in the U.S. manufacture hepatitis B vaccine? Final Jeopardy

Who are…..?                                                                   Final Jeopardy

Thank you for playing Hepatitis Jeopardy

The diagnosis of acute HAV infection is confirmed during the acute or early convalescent phase of infection by the presence of IgM antibodies to HAV (IgM anti-HAV). IgM anti-HAV is generally present 5-10 days into the incubation period and remains detectable for up to 6 months after onset of illness. IgG anti-HAV, which also appears early in the course of infection, remains detectable for the lifetime of the individual and confers lifelong protection against infection. Commercial tests are available for the detection of IgM and total (Igm and IgG) anti-HAV in serum. In infected persons, HAV replicates in the liver, is excreted in bile, and is shed in the stool. Peak infectivity occurs during the 2-week period before onset of jaundice or elevation of liver enzymes, when the concentration of virus in stool is highest. The concentration of virus in stool declines after jaundice appears. Children and infants can shed HAV for longer periods than adults, up to several months after the onset of clinical illness. Chronic shedding of HAV in feces does not occur; however, shedding can occur in persons who have relapsing illness. Viremia occurs soon after infection and persists through the period of liver enzyme elevation. HAV RNA can be detected in the blood and stool of most persons during the acute phase of infection by using nucleic acid amplification methods, and nucleic acid sequencing has been used to determine the relatedness of HAV isolates. However, these methods, available in only a limited number of research laboratories generally are not used for diagnostic purposes.

Acute Hepatitis A: Case Definition Clinical criteria: Discrete onset of symptoms and Jaundice or elevated serum aminotransferase levels Laboratory criteria IgM anti-HAV-positive Case Classification Confirmed. A case that meets the clinical case definition and is laboratory confirmed or a case that meets the clinical case definition and occurs in a person who has an epidemiological link. Acute hep C a reportable condition since ..... Case definition... Reported since ____ through NNDSS and NETSS Grouped with NANB hepatitis because of limitations of diagnostics

Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Symptoms HBeAg anti-HBe Total anti-HBc IgM anti-HBc anti-HBs HBsAg 4 8 12 16 20 24 28 32 36 52 100 Titer 30

Acute Hepatitis B: Case Definition Clinical criteria: Discrete onset of symptoms and Jaundice or elevated serum aminotransferase levels Laboratory criteria IgM anti-HBc-positive or HBsAg-positive, if IgM anti-HBc not done Case Classification Confirmed. A case that meets the clinical criteria and is IgM anti-HBc-positive Suspected. A case that meets the clinical criteria, is HBsAg-positive and IgM anti-HAV-negative, but was not tested for IgM anti-HBc. Acute hep C a reportable condition since ..... Case definition... Reported since ____ through NNDSS and NETSS Grouped with NANB hepatitis because of limitations of diagnostics

Chronic Hepatitis B Virus Infection Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course IgM anti-HBc Total anti-HBc HBsAg Acute (6 months) HBeAg Chronic (Years) anti-HBe 4 8 12 16 20 24 28 32 36 52 Years Weeks after Exposure Titer 31

Chronic HBV Infection: Case Definition Clinical criteria: Most are asymptomatic. However, many have CLD, which can range from mild to severe. Laboratory criteria: HBsAg-positive two times at least 6 months apart, or HBsAg-positive, total anti-HBc-positive and IgM anti-HBc-negative Acute hep C a reportable condition since ..... Case definition... Reported since ____ through NNDSS and NETSS Grouped with NANB hepatitis because of limitations of diagnostics

Acute HCV Infection with Recovery Typical Serologic Course HCV RNA Symptoms +/- Time after Exposure Titer Anti-HCV ALT Normal 1 2 3 4 5 6 Years Months

Acute Hepatitis C: Case Definition Clinical criteria: Acute illness with discrete onset of symptoms and Jaundice or elevated serum aminotransferase levels Laboratory criteria Serum aminotransferase levels >7 times ULN and IgM anti-HAV-negative and IgM anti-HBc-negative (if done) or HBsAg-negative and anti-HCV-positive and verified by additional more specific assay or Anti-HCV-positive by RIBA alone or HCV RNA positive Acute hep C a reportable condition since ..... Case definition... Reported since ____ through NNDSS and NETSS Grouped with NANB hepatitis because of limitations of diagnostics

Progression to Chronic HCV Infection Typical Serologic Course Symptoms +/- Time after Exposure Titer anti-HCV ALT Normal 1 2 3 4 5 6 Years Months HCV RNA

Chronic or Resolved HCV Infection: Case Definition Clinical criteria: Most are asymptomatic. However, many have CLD, which can range from mild to severe. Laboratory criteria Anti-HCV-positive (by EIA), either verified by an additional, more specific assay (e.g., RIBA or PCR for HCV RNA), or with signal-to-cut-off (SCO) ratio of >3.8 Case Classification Confirmed: Laboratory confirmed Probable: Abnormal ALT values but anti-HCV result not verified by more specific assay and SCO unknown Acute hep C a reportable condition since ..... Case definition... Reported since ____ through NNDSS and NETSS Grouped with NANB hepatitis because of limitations of diagnostics

CASE STUDY 1

Kelly went on a trip to Peru two years ago Kelly went on a trip to Peru two years ago. One week prior to her trip, she received one dose of IG. She got the first dose of hepatitis A vaccine at the same time. She returned from her two week trip, returned to her job at the health department, and as usual was crazy busy. Two years elapsed when she finally went to her doctor for her second dose of vaccine.

Did she need the IG prior to travel or would the vaccine have been adequate? Yes, she needed the IG. At least 4 weeks needs to transpire between the 1st dose of vaccine and travel. Given the elapsed time between the 1st and 2nd dose is Kelly now protected from HAV infection? Yes, Why?

Hepatitis A vaccine is very immunogenic - general thought is that time can lapse between doses without compromising immunity. Studies have shown that protective antibody levels developed in 94%-100% of adults one month after the first dose. After the second dose, all persons had protective levels of antibody. If Kelly had four weeks prior to traveling to Peru, she would not have needed IG, only the first dose of hepatitis A vaccine.

Should post vaccination testing be done on persons who received hepatitis A vaccine? No, Why? Hepatitis A vaccine is very immunogenic and the assay may not be adequate to pick up true protection.

How long does immunity last after hepatitis A immunization? Although data on long-term protection are limited, estimates based on modeling techniques suggest that protection will last for at least 20 years. Should pre-vaccination testing be done? Generally no, pre-vaccination testing is done only in specific instances to control cost.

Other than travelers to HAV endemic areas, what other groups would you recommend hepatitis A vaccine? MSM Illegal drug users, both injecting and non-injecting Children living in communities with consistently increased rates of hepatitis A or periodic outbreaks. Persons with CLD Persons working with live virus Persons with clotting factor disorders

What is TWINRIX? On May 11, 2001, The Food and Drug Administration (FDA) licensed a combined hepatitis A and hepatitis B vaccine (Twinrix) for adults. The antigenic components in Twinrix have been used routinely in separate vaccines since 1995 and 1989 for hepatitis A and hepatitis B vaccines, respectively. Primary immunization consists of three doses (0,1,6).

CASE STUDY 2

When Lester and Joan Talbot sold their family-owned bakery for a cool 3 million dollar profit, they retired and rewarded themselves by booking a year-long trip around the world on the Good Luck Cruise Line. At one of the numerous mid-afternoon all-u-can-eat seafood buffets, Lester and Joan partook of copious amounts of raw oysters on the half-shell, lobster tails and peel & eat shrimp (later to have been found to have been dredged from unlicensed beds) . Five weeks later when their ship docked in Puerto Vallarta, Mexico, they were not feeling so well. Both were having flu-like symptoms that included nausea, vomiting, diarrhea, and slight fever. When Lester looked into Joan=s eyes, he noted that the usual white had turned to yellow. The ship=s doctor sent their blood out to be tested.

The ship’s Dr. ran a hepatitis panel on Lester, his results were: HBsAg – positive Total anti-HBc – positive IgM anti-HBc – negative Total anti-HAV – positive IgM anti-HAV – positive Anti-HCV EIA – positive with SCO of 3.0 ALT – 2,000 (ULN – 45) AST – 1000 (ULN – 55) What does Lester’s serologic results indicate?

Total anti-HBc – positive IgM anti-HBc – negative HBsAg – positive Total anti-HBc – positive IgM anti-HBc – negative Total anti-HAV – positive IgM anti-HAV – positive Anti-HCV EIA – positive with SCO of 3.0 ALT – 2,000 (ULN – 45) AST – 1000 (ULN – 55) He has chronic HBV infection, acute hepatitis A, and possible HCV infection

What should Lester be told? He has chronic HBV infection, acute hepatitis A, and possible HCV infection What should Lester be told? He should see a specialist for management of his chronic hepatitis B He needs a confirmatory hepatitis C test, as his SCO is only 3.0 All of his household and sex contacts (if not immune) should be vaccinated against hepatitis B

The ship’s Dr. ran a hepatitis panel on Joan, her results were: HBsAg – negative Total anti-HBc– negative IgM anti-HBc – negative Total anti-HAV – positive IgM anti-HAV – positive ALT – 1000 (ULN – 45) AST – 500 (ULN –55) Anti-HCV EIA – negative What does Joan’s serologic results indicate?

She has acute hepatitis A. HBsAg – negative Total anti-HBc– negative IgM anti-HBc – negative Total anti-HAV – positive IgM anti-HAV – positive ALT – 1000 (ULN – 45) AST – 500 (ULN –55) Anti-HCV EIA – negative She has acute hepatitis A.

She has acute hepatitis A. What should Joan be told? She should be vaccinated against hepatitis B. If she has other sex contacts, they should receive IG. She should get post vaccination testing for hepatitis B.

Lester had a RIBA test, and the result was negative Lester had a RIBA test, and the result was negative. What does this indicate? Lester is not infected with HCV, the EIA anti-HCV test was a false positive

CASE STUDY 3

A 40 year old pregnant women is due March 28, 2002 A 40 year old pregnant women is due March 28, 2002. She had one dose of hepatitis B vaccine in 1998 (was planning a trip to Turkey, but cancelled). She tested negative for HBsAg in spring 2001 during a prenatal exam. She subsequently miscarried in April 2001 but became pregnant again in July 2001. She is in good health, has no allergies, and does not take any medications.

Test results were as follows: July 30, 2001 HBsAg – positive September 10, 2001 HBsAg – positive anti-HBs – negative anti-HBc – negative IgM anti-HBc – negative

IgM anti-HBc – negative November 1, 2001 HBsAg – positive anti-HBs – not done anti-HBc – negative IgM anti-HBc – not done January 3, 2002 HBsAg – negative anti-HBs – negative anti-HBc – negative IgM anti-HBc – negative

Do you recommend any further testing? Is she infected with hepatitis B virus? Probably not, anti-HBc has been negative the entire time. Do you recommend any further testing? Yes. Should be tested for HBsAg right before delivery.

Should her baby be given H-BIG and the first does of hepatitis B vaccine at birth? Depends on HBsAg testing prior to delivery. Would certainly be sure to start the vaccine series at birth – only add H-BIG if she tests HBsAg – positive.

CASE STUDY 4

In September 1999, a woman of Southeast Asian descent who tested negative for hepatitis B gave birth to a seemingly healthy baby girl. In December, the 3 month-old infant was hospitalized following 5 days of fever, diarrhea and jaundice. Hepatitis B serology on the baby was performed on admission: HBsAg - positive IgM anti-HBc - positive ALT - 693; T. bili - 16.6 The mother was tested at the same time and was found to be HBsAg-positive and IgM anti-HBc-negative What do these serologic pictures indicate?

The baby has acute hepatitis B The mother has chronic hepatitis B How could this have happened and how could this have been prevented? At the time of birth, the mother’s test result was falsely communicated as “hepatitis negative” to the hospital where the infant was born. The baby died 4 days after hospitalization from fulminant hepatic failure secondary to acute hepatitis B. This could have been prevented by routine administration of birth dose regardless of mother’s reported HBsAg status. Obtain actual lab REPORT, not just verbal communication or something copied out of a chart

Other lessons HBsAg status should always be communicated to the mother along with its importance Women should have screening done for each separate pregnancy regardless of results from a prior pregnancy and regardless of hepatitis B vaccination status Providers at the time of labor & delivery should obtain actual lab report, not just verbal communication or a result copied from one chart to another– mistakes do occur

CASE STUDY 5

Pete went to his doctor with jaundice, fatigue and abdominal pain Pete went to his doctor with jaundice, fatigue and abdominal pain. After reviewing Pete’s liver panel, the Dr. diagnosed him with acute hepatitis B.

With a diagnosis of acute hepatitis B , what would his liver serologic results look like? HBsAg HBeAg Total anti-HBc IgM anti-HBc Anti-HBeAg Anti-HBs ALT positive positive positive positive negative negative 2,000 (ULN – 45)

What does this serologic picture mean? On the same day another patient, Joe, comes in to the doctor complaining of a headache – he stated that he had sex contact with Pete, so the doctor does a hepatitis B panel and finds the following. HBsAg – positive HBeAg - positive Total anti-HBc – positive IgM anti-HBc – negative Anti-HBs – 6mIU/mL What does this serologic picture mean? Pete’s friend, Joe has chronic hepatitis B.

Biologically insignificant. What significance is the anti-HBs? Biologically insignificant.

What does this serologic picture mean? Joe was very upset and told his friend Henry, with whom he had a sexual relationship with in the distant past. Henry immediately went to his doctor. Henry’s doctor did a hepatitis panel and found the following. HBsAg – negative Total anti-HBc – positive Anti-HBs – negative Total anti-HAV – positive IgM anti-HAV – negative Anti-HCV – negative What does this serologic picture mean?

May be recovering from acute HBV infection. HBsAg – negative Total anti-HBc – positive Anti-HBs – negative Total anti-HAV – positive IgM anti-HAV – negative Anti-HCV – negative May be recovering from acute HBV infection. May be distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum. May be susceptible with a false positive anti-HBc. May be undetectable level of HBsAg present in the serum and the person is actually a low level carrier. History of HAV infection.

CASE STUDY 6

Test results were as follows: Mary has been a long term illegal injection drug user. She is now pregnant. Her obstetrician; knowing her drug use history, ordered a panel of hepatitis tests during her first trimester. Test results were as follows:

What does this serologic picture indicate? HBsAg – negative anti-HBc – positive IgM anti-HBc – negative Anti-HBs – positive Anti-HAV – positive IgM anti-HAV – negative Anti-HCV EIA – positive (with a signal to cut-off – 3.9) What does this serologic picture indicate?

History of hepatitis B – now immune HBsAg – negative anti-HBc – positive IgM anti-HBc – negative Anti-HBs – positive Anti-HAV – positive IgM anti-HAV – negative Anti-HCV EIA – positive (with a signal to cut-off – 3.9) History of hepatitis B – now immune History of hepatitis A – now immune HCV infection

Does supplemental testing with RIBA need to be done? No, Why? SCO of 3.8 or above is reported as positive? What else should be done? Referral to specialist to determine if she has chronic liver disease.

CASE STUDY 7

A 27 year old women presents to the ER with a history of 4-5 days of malaise, fatigue, low-grade fever and nausea. Yesterday she noted that her urine became very dark. She is sexually active and in good health.

What hepatitis specific serologic tests would you consider appropriate? HBsAg IgM anti-HBc IgM anti-HAV EIA anti-HCV liver enzymes

Results positive HBsAg IgM anti-HBc IgM anti-HAV positive EIA anti-HCV negative positive

Based on the findings what is her serologic diagnosis? positive HBsAg IgM anti-HBc IgM anti-HAV EIA anti-HCV positive negative positive Based on the findings what is her serologic diagnosis? Acute hepatitis B, possible HCV infection

What should you do regarding the positive EIA anti-HCV result? Preferably order a RIBA (could do HCV RNA, but RIBA is probably the best choice). Results RIBA - positive What does this mean? She has HCV infection.

Thank you!